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Nasogastric tube placement in the stomach is required for enteral nutrition, for medication in critically ill patients, and for evacuation of stomach content to prevent aspiration pneumonitis. Nasogastric tube placement is associated with mechanical complications such as ulceration and bleeding from the nose, pharynx, esophagus, and stomach (1). Accidental insertion of the nasogastric tube into the tracheopulmonary system during placement is associated with significant morbidity such as pneumothorax, hemothorax, or even death (2–4). We report a case of knotting of the nasogastric tube over the epiglottis leading to life-threatening respiratory distress in a spontaneously breathing postoperative patient having received a living related liver transplant.

Case Report

A 36-yr-old woman weighing 48 kg diagnosed with hepatitis C virus-related liver cirrhosis with portal hypertension was scheduled to undergo a living related liver transplant. Anesthesia and surgery were uneventful. Total duration of surgery was 18 h. After induction of anesthesia and endotracheal intubation, an 18F nasogastric (NG) tube was placed through the right nostril into the stomach in the first attempt without difficulty. Proper placement of the NG tube was checked by auscultation over the stomach while injecting 10 mL air with a disposable syringe into the NG tube and also by aspiration of stomach contents. Postoperatively the patient was shifted to the surgical intensive care unit for elective ventilation and monitoring. On the second postoperative day the patient was conscious, obeying commands, hemodynamically stable, had good respiratory efforts with satisfactory blood gases, and was thus tracheally extubated. Thereafter, the patient breathed 40% oxygen through a Ventimask. Her arterial blood gases were well maintained and pulse oximeter displayed a saturation of more than 98% throughout the case. Eight hours after extubation, the patient had a sudden bout of coughing after which she complained of choking, respiratory discomfort, tachypnea, dyspnea, and cyanosis. Therefore emergency reintubation was attempted. During laryngoscopy for intubation, the NG tube was observed to be coiling around the epiglottis. On withdrawing the NG tube for relieving the coiling, it formed a knot over the epiglottis. We therefore proceeded with the emergency intubation by directly lifting the epiglottis via the laryngoscope blade and the patient was connected to the ventilator. No part of the NG tube was seen passing through the vocal cords. Subsequently, the knot over the epiglottis was released with the help of the Magill’s forceps. The patient was given 100 mg hydrocortisone for any edema of the epiglottis. She died on the seventh postoperative day of fungal infection, septicemia and renal failure.

Discussion

Over the last two decades, the narrow bore enteral feeding tube has gained widespread acceptance as compared to the rigid large-bore type. The narrow tube is softer, made from polyvinyl chloride/silastic and generally provides greater patient comfort and fewer complications (such as ulceration and bleeding from the nose, pharynx, larynx, esophagus, and stomach) than the stiffer large-bore tube. Inadvertent placement of the NG tube into the tracheopulmonary system has been reported in 2% of cases (2,5). NG tube placement results in pneumothorax/hemothorax in 0.2%–0.7% of the patients (2,5–7). Mortality associated with NG tube insertion is approximately 0.3%(2–4). Fluoroscopy, laryngoscopy, and endoscopically guided insertion of the NG tube have been advised to circumvent these complications (3,4,7). However, all these techniques increase the cost of the treatment as well as the time taken for insertion and require the availability of a specialist. Chest radiography is recommended before initiation of feeding in all cases after NG tube placement in high-risk unconscious patients or those with tracheotomies.

Pushing or pulling of the NG tube after it has been successfully placed into the stomach either by an operator or spontaneously via neck movement or deglutition/coughing may lead to formation of a loop in the pharynx. This loop may encircle the pharyngeal structures like the epiglottis in which case pulling the NG tube will further tighten its grip around the encircled structure. If the NG tube rotates in the pharynx it may form a knot around that particular structure.

We report knotting of the NG tube over the epiglottis leading to respiratory distress in a spontaneously breathing patient. Though this is a rare occurrence it is a dangerous one. The possibility of NG tube knotting should be kept in mind with regard to any patients who have an NG tube in place and subsequently develop respiratory distress of sudden onset.